Advances in Neurosurgery 6 Treatment of Hydrocephalus
Computer Tomography
Edited by R. WUllenweber H. Wenker M. Brock M. Klinger
With 111 Figures and 86 Tables
Spri nger-Verlag Berlin Heidelberg New York 1978 Proceedings of the Joint Meeting of the Deutsche Gesellschaft fUr Neurochirurgie, the Society of British Neurological Surgeons, and the Nederlandse Vereniging van Neurochirurgen Berlin, May 3-6,1978
ISBN-13: 978-3-642-67084-8 e-ISBN-13: 978-3-642-67082-4 DOl: 10.1007/978-3-642-67082-4
Library of Congress Cataloging in Publication Data. Deutsche Gesellschaft fOr Neuro' chirurgie. Treatment of hydrocephalus; Computer tomography. (Advances in neurosurgery; v.6) Includes bibliographies and index. 1. Brain·Diseases-Diagnosis-Congresses. 2. Hydrocephalus-Surgery-Congresses. 3. Tomography-Congresses. 4. Brain-Diseases• Congresses. I. WUllenweber, R., 1924-. II. Title. III. Series. [DNLM: 1. Hydrocephalus• Surgery-Congresses. 2. Cerebrospinal fluid shunts-Adverse effects-Congresses. 3. Tomography, Computerized AXIAL-Congresses. WI AD684N v.6 / WL350 T784] RC386.6.T64D481978 616.8'04'7572 78-10202
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The use of registered names, trademarks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protec• tive laws and regulations and therefore free for general use. Preface
More than 40 years ago British and German neurosurgeons met in Berlin and Breslau to exchange their experiences, to strengthen their friendly bonds, and to enjoy the attractions of both cities and their surroundings. In 1960 a joint meeting of the Dutch and German societies took place in Rotterdam by invitation of the Nederlandse Vereniging van Neurochirurgen. All who attended this meeting thankfully remember the great hospitality during these unforgettable days. In 1970, by courtesy of the Society of British Neurological Surgeons, German neurosurgeons had the pleasure to become acquainted with the great tradition of British sciences at one of the most famous places during the meeting in Cambridge. These impressions were deepened by visits to other famous sources of British scientific tradition during the European Congress in Oxford in 1975. The critical distance sometimes necessary towards our own discipline is implicit in the major themes of this meeting. Complications following shunting procedures for hydrocephalus have been discussed on the basis of the results of a cooperative study of some German neurosurgical departments. The second main topic was problems and diagnostic errors in computer tomography. The papers presented contain critical considerations about the findings obtained by this method, as well as on its possibilities and limitations. German neurosurgeons felt deeply indebted to their British and Dutch colleagues and wanted to return their kindness at this joint meeting in Berlin. We hope that all participants will retain pleasant memories of the days in this city. In the name of the German Society for Neurosurgery, the organizers of the Joint Meeting in Berlin express their gratitude to Professor G. Finger of Sharp & Dohme GmbH Miinchen for generously supporting the publication and distribution of Advances in Neurosurgery 6.
Horst Wenker Rolf Wiillenweber
v Reminiscences of the Meeting of 1937 and of Otfrid Foerster1 c. GUTIERREZ2
There are two steps to be taken by those who wish to advance a medical specialty: the formation of a society and the publication of a journal. The birth of the first neurosurgical society was reported by Ernest SACHS in his autobiography [27]: Harvey CUSHING delivered a memorable address on his brain tumor statistics in 1919 before the American College of Surgeons with William MAYO in the chair. At the conclusion Dr. MAYO announced solemnly: "Gentlemen, we have this day witnessed the birth of a new specialty - neurological surgery". After the meeting CUSHING was congratulated by many and he said enthusiastically: "Wouldn't it be a good idea to get the fellows interested in this work together? Why not form a society and hold regular meetings in which we could discuss our problems and compare results? In this way we could make much more rapid progress." This suggestion was followed and the first meeting was held in Boston in 1920. CUSHING was elected president, SACHS secretary, and the first neurosurgical society was founded. The first neurosurgical journal, the Zentralblatt fur Neurochirurgie, was started in Germany in 1936 by TONNIS [15] but not until 1948 was the Deutsche Gesellschaft fur Neurochirurgie founded [8]. The societies mentioned above were established by surgeons. It was different in the Netherlands. The Dutch Study Club for Neurosurgery was formed in 1936 [29], the membership consisting of four neurologists and four neurosurgeons. The initiative came from a neurosurgeon, VERBECK, but it was the neurologist BROUWER, who was the driving force. He was elected the first president and remained so until his death in 1949. The Nederlandse Vereniging van Neurochirurgen was founded in 1952 [29]. When the Society of British Neurological Surgeons (SBNS) was created by Geoffrey JEFFERSON in 1926, it intended to hold two meetings each year, at home in winter and abroad in summer. The first meeting abroad was held in Paris in 1930 and the next in Amsterdam in 1932 which I attended and found wonderfully rich in culture and hospitality, but not very stimulating neurosurgically. I remember how disappointed BROUWER was when OLjENICK, the neurosurgeon in his clinic, outdid CUSHING as regards the most minute operating details, performed a ventricular estimation (which was in fashion at that time), but when he opened the skull he did not find the tumor. The specialty hat not yet gotten on its feet in Holland, but soon thereafter de VET, LENSHOEK, VERBECK, and VERBRIEST brought it to a proper high standard. The summer meeting of 1937 [16, 31] was held in Berlin and Breslau, and again I was a guest of the SBNS. The three days in Berlin included visits to the Neurosurgical Clinic of TONNIS, the Kaiser-Wilhelm-Institut fur Hirnforschung and SAUERBRUCH'S Clinic. A joint meeting was held with the Berlin Medical Society, where President MCCONNELL of
1 Society of British Neurological Surgeons, 29 June to 3 July 1937 at Berlin and Breslau. 2 Institute of the History of Medicine and Neurosurgical Clinic of the University of Gottingen.
VI the SBNS lectured on the Chiasmal Syndrome [20,21]. The principal topic of the meeting [32] was intracranial tumors, their nature, and their diagnosis with ventriculography, arteriography and EEG. The distinction from pseudotumor cerebri was discussed by NONNE who had coined the term in 1904 [23]. Other matters considered were subdural hematomas, spasmodic torticollis, and the importance of angiography for the diagnosis and treatment of aneurysms. Among those who read papers were BUSCH (Copenhagen), BERGSTRAND, OLIVECRONA, RINGERTZ and SJOQVIST (Stockholm), TORKILDSEN (Oslo), NONNE (Hamburg), SCHAL TENBRAND (Wiirzburg), and OSTERTAG, SPATZ and ZULCH (Berlin). The trip to Breslau to honor FOERSTER and to visit his institute was especially interesting and pleasant. FOERSTER had close neurological connections with England, having been a devoted disciple of HUGH LINGS JACKSON and of SHERRINGTON. He had given three lectures under the auspices of London University in 1931 [10], the SCHORSTEIN Lecture at the London Hospital in 1932 [11], and the HUGHLINGS JACKSON Centennial Memorial Lecture of the Royal Society of Medicine in 1935 [14]. He was made Emeritus Member of the SBNS at the Breslau meeting where he entertained and instructed us royally with three lectures. These formed a report of the 552 verified tumors of the nervous system which he had collected in 17 years from 12000 admissions to his Neurological Department at the Wenzel-Hancke-Krankenhaus. The social activities included a supper for the entire company at FOERSTER'S villa in Scheitniger Park to which the visitors were transported in a specially provided tram, FOERSTER being of the opinion that the town could be seen better and more comfortably from a tram than from a taxi. FOERSTER restricted his work to Neurology and dedicated all his efforts to establishing neurology as an independent specialty [24]. Neurology had been a stepchild in Germany, at first of internal medicine, later of Psychiatry. ROMBERG, Professor of Therapeutics in Berlin, wrote the first textbook of Neurology in 1840 [26], having been influenced by the writings of Charles BELL, which he translated in 1832 [1]. Soon afterwaards GRIESINGER wrote the first German textbook of psychiatry in 1845 [19], and, declaring that mental illness was due to disease of the brain, brought psychiatry and neurology together for treatment and teaching. This set some psychiatrists to the very productive anatomical study of the brain, among whom were MEYNERT, FOREL, WERNICKE, NISSL and ALZHEIMER. But FOERSTER felt strongly that the field was too wide for one man to straddle and do justice to both specialties, thereby impeding the development of neurology [12]. But in spite of his constant efforts for 40 years, the German regulations for medical education and examination in 1966 [25] still lumped psychiatry and neurology together and stated that the examination in neurology might be conducted by an examiner of internal medicine. When FOERSTER qualified as a physician in 1897 [5], he went to Heiden in Switzerland to study with H. S. FRENKEL and to the DEJERINES in Paris. Straight away he started physiological studies on the sensation and gait of patients with tabes dorsalis [6], which formed the basis for his great success with the treatment of pain, the relief of spastic paralysis, and exercise therapy. Within ten years on 3 May 1907, he directed the performance by TIETZE of the FOERSTER operation, the division of posterior roots for the treatment of spastic paralysis [9]. This was the beginning of physiological neurosurgery. At the same time he continued the study of movement and further developed the field of exercise therapy [7], now known as rehabilitation, to which he contributed consecutively
VII for 40 years [13]. FOERSTER prepared Ludwig GUTTMANN, who was his assistant for several years, to extend the field of rehabilitation. GUTTMANN did this with great zeal and success, but without giving FOERSTER any sign of recognition or of gratitude for the great debt he owed his master. Sadly, GUTTMANN had suffered for political reasons and had to leave his position in the hospital with FOERSTER in 1933. He complained unjustly that FOERSTER had not protected him, although he secured an appointment for GUTTMANN in another hospital in Breslau. But who was able to oppose the will of HITLER at that time? Nevertheless, Germany's loss was England's gain, and thousands of neurologically disabled throughout the world have benefitted, through GUTTMANN, from FOERSTER'S neurophysiological research and teaching. FOERSTER encountered many obstructions to his efforts for the liberation of Neurology. The greatest opposition came from psychiatrists such as BONHOEFFER, who considered themselves competent as neurologists and maintained that they should continue to direct both psychiatry and neurology [2, 34]. The fallacy of their opinion has been proven by the relatively few contributions made by them to the progress of Neurology. The field is too great for one man to be productive in both specialties.
BONHOEFFER was assistant to WERNICKE in Breslau for 10 years, from January 1893 until October 1903, and succeeded him in October 1904 as Director of the Psychiatric and Nervenklinik. He left Breslau for Berlin in 1912 [4]. FOERSTER was an assistent in the clinic and laboratory of WERNICKE from 1899 until October 1904. Thereafterfor several years FOERSTER'S papers were published from the surgical separtment of Prof. TIETZE in the Allerheiligen Hospital. Little is known about the relationship between BONHOEFFER and FOERSTER but it is striking, that in his autobiography [4] BONHOEFFER did not once mention the name of FOERSTER, although he wrote interestingly about his colleagues and life in Breslau for about 20 years. During 12 of these FOERSTER was there, and for 4 years they were both in WERNICKE'S department. BONHOEFFER was in Breslau to live through FOERSTER'S becoming Privatdocent in 1903 [8], titular professor in 1909, and head of an independent Neurological Department at the Allerheiligen Hospital in 1911. FOERSTER must have been very difficult for BONHOEFFER to overlook and, much more so, to swallow. BONHOEFFER was just as determined to keep Neurology under the control of Psychiatry as FOERSTER was opposed. The battle smouldered until it burst into flame at the time of the First International Neurological Congress at Bern in 1931 [17,18]. MINKOWSKI, the neurologist in Zurich, who had been trying to make Neurology independent in Switzerland, published data [22] to show that the development of Neurology in Germany was far behind that in a number of less important countries. BONHOEFFER [3] reacted vigorously to the report and the recommendations of MINKOWSKI. FOERSTER replied with an eloquent rebuttal of BONHOEFFER'S arguments [12]. FOERSTER'S forthright comments on BONHOEFFER'S attitude at this time may be attributed to a confidence he acquired that Neurology was gaining ground, after the discussion he had in October 1930 about "Neurology in Germany" with Dr. Alan GREGG, who was head of the Medical Sciences Division of the Rockefeller Foundation. They developed a plan to make Neurology an independent specialty in Germany which appeared to lead to a certain success. It consisted in a promise that the Rockefeller Foundation would build a Neurological Research Institute in Breslau, to be controlled by the University, if the City
VIII of Breslau, the Province of Silesia, and the State of Prussia would supply funds for the upkeep of the institute, and the Prussian Ministry of Science, Art and National Education would establish a Chair of Neurology in the University. After 2 years of tedious and strenuous work FOERSTER was able to assure the upkeep of the institute, but not the keystone of the plan, since the Ministry found it impossible to establish even one new chair in any university, because of the grievious state of the economy at that time. FOERSTER was almost in despair, but the Ministry did promise to make his professorship permanent and to continue it for his successors. This satisfied the Rockefeller Foundation, so the institute was built and it was opened in 1934. It was there that the Breslau meeting of the SBNS was held in 1937. After FOERSTER'S death in 1941 it was named the Otfrid FOERSTER Institute [30].
References
1. BELL, K.: Physiologische und pathologische Untersuchungen des Nervensystems. Translated by ROMBERG, H. Berlin: Stuhr 1832 2. BONHOEFFER, K.: Psychiatrie und Neurologie. Monatschr. Psychiat. Neurol. 37,94-104 (1915) 3. BONHOEFFER, K.: Zur Stellung der Neurologie im medizinischen Unterricht und in den allgemeinen Krankenhausern. Monatschr. Psychiatr. N eurol. 83, 180-186 (1932) 4. BONHOEFFER, K.: Lebenserinnerungen von Karl Bonhoeffer geschrieben fUr die Familie. In: Karl Bonhoeffer zum hundersten Gebunstag am 31. Marz 1968. Zurr, J., STRAUS, E., SCHELLER, H. (eds.), pp. 8-107. Berlin, Heidelberg, New York: Springer 1969 5. FOERSTER, 0.: Quantitative Untersuchungen uber die agglutinirende und baktericide Wirkung des Blutserums von Thyphus-Kranken und -Reconvalescenten. Inaugural-Dissertation, Breslau. Leipzig: Veit 1897 6. FOERSTER, 0.: Zur Symptomatologie der Tabes dorsalis im praeataktischen Stadium und uber den Einflull der Optikusatrophie auf den Gang der Krankheit. Monatschr. Psychiatr. Neurol. 8, 1-14, 134-150 (1900) 7. FOERSTER, 0.: Dbungstherapie bei Tabes dorsalis. Dt. Aerzte-Z. 100-104, 128-131 (1901) 8. FOERSTER, 0.: Beitrage zur Kenntnisse der Mitbewegungen. Jena: Fischer 1903 9. FOERSTER, 0.: Dber eine neue operative Methode der Behandlung spastischer Lahmungen mittels Resektion hinterer Ruckenmarkswurzeln. Z. Orthop. Chir. 22, 203-223 (1908) 10. FOERSTER, 0.: The cerebral cortex in man. Lancet 2,309-312 (1931) 11. FOERSTER, 0.: The dermatomes in man. Brain 56,1-39 (1933) 12. FOERSTER, 0.: Eroffnungsrede 21. Jahresversammlung der Gesellschaft deutscher Nervenarzte, Wiesba• den 1932. Dt. Z. Nervenheilkd. 129.175-184 (1933) 13. FOERSTER, 0.: Dbungstherapie. In: Handbuch der Neurologie. BUMKE, 0., FOERSTER, O. (eds.), Vol. 8, pp. 316-414. Berlin: Springer 1936 14. FOERSTER, 0.: The motor cortex in man in the light of HUGHLING JACKSONS doctrines. Brain 59,135-159 (1936 ) 15. FOERSTER, 0.: Zum Geleit. Zentral. Neurochir. 1,2-3 (1936) 16. FOERSTER, 0.: Zur 22. Tagung der Society of British Neurological Surgeons vom 29. Juni bis 3. Julil1937 in Berlin und Breslau. Zentralbl. Neurochir. 2, 213 (1937) 17. FOERSTER, 0.: Adress at the official dinner of the 1st Int. Neurol. Congr., Bern, 3 September 1931. Bull. Hist. Med. 8,351-353 (1940) 18. FOERSTER, 0.: Rede auf dem Internationalen Neurologenkongrell in Bern 3. 9.1931. In: Einfuhrungindie Neurologie. HAGEL, O. (ed.) pp. IV-V. Berlin, Gottingen, Heidelberg: Springer 1949 19. GRIESINGER, W.: Die Pathologie und Therapie der psychischen Krankheiten fur Arzte und Studierende. Stuttgart: Krabbe 1845 20. KOELSCH: Berliner Medizinische Gesellschaft. Gemeinsame Sitzung mit der Society of British Neurologi• cal Surgeons in Berlin. Sitzung vom 30. Juni 1937. Klin. Wschr. 16,1443-1444 (1937) 21. MCCONNELL, A. A.: Dber das Chiasmasyndrom. Dtsch. Med. Wschr. 64, 186-191 (1938) 22. MINKOWSKI, M.: Ergebnisse einer internationalen Enquete uber die Stellung der Neurologie 1m medizinischen U nterricht. Schweizer Arch. N eurol. Psychiatr. 27, 311-320 (1931)
IX 23. NONNE, M.: Dber Falle Yom Symptomenkomplex "Tumor cerebri" mit Ausgang in Heilung (Pseudotu• mor cerebri). Dber letal verlaufene Falle yom "Pseudotumor cerebri" mit Sektionsbefund. Dtsch. Z. Nervenheilkd. 27, 169-216 (1904) 24. PETIE, H.: Otfried Foerster. Der Kampfer urn eine selbstandige Neurologie. In: Forscher und Wissenschaftler im heutigen Europa. SCHWERTE, H., SPENGLER, W. (eds.), pp. 93-100. Oldenburg: Stalling 1955 25. RACHOLD, R.: Bestallungsordnung fur Arzte. Kaln-Berlin: Deutscher Arzte-Verlag 1966 26. ROMBERG, M. H.: Lehrbuch der Nervenkrankheiten des Menschen. Berlin: Duncker 1840 27. SACHS, E.: Fifty years of neurosurgery. New York: Vantage 1958 28. TONNIS, W.: Eraffnungsansprache des Vorsitzenden der 1. Neurochirurgischen Tagung, Freiburg/Br., 2.-4. September 1948. Dtsch. Z. Nervenheilkd. 162,6-8 (1950) 29. VET, A. de: The history of Neurosurgery in the Netherlands. Read before the Nederlandse Verenigingvan Neurochirurgen Nijmegen 1971 30. WEIZSACKER, V. v.: Nachruf auf Otfried Forster gesprochen bei seiner Bestattung am 19. VI. 1941. Nervenarzt 14, 385-386 (1941) 31. ZULCH, K. J.: Bericht uber das Treffen der Society of British Neurological Surgeons in Berlin and Breslau. Munch. Med. Wschr. 84, 1474-1475 (1937) 32. ZOLCH, K. J.: Tagungsbericht des Treffens der Society of British Neurological Surgeons yom 29. Juni bis 3. Juli 1937 in Berlin und Breslau. Zentbl. Neurochir. 2, 352-366 (1937) 33. ZOLCH, K. J.: Erste Tagung deutscher Neurochirurgen in Freiburg i. Brsg. Yom 2.-4. September 1948. Zentralbl. Neurochir. 9, 248-257 (1949) 34. ZUTT, J.: Psychiatrie und Neurologie. Nervenarzt 33,1-6 (1962)
x The Development of Neurosurgery in Berlin
R. WOLLENWEBER
Until the end of the Second World War, the street which lies between Brandenburg Gate and the Victory Column was named "Siegesallee" (Victory Avenue). As it was embellished with a collection of esthetically unremarkable statues, it was more pertinently described in the Berlin vernacular as "Puppenallee" (Dummy Avenue). At the midpoint of the street stood a statue of Markgraf Otto the Fourth "with the arrow". This margrave, head of the older Askanian line at the end of the 13th century, had suffered a head wound by an arrow in the course of one of his many battles, but this arrow was not removed for more than one year thereafter. The fact so impressed his posterity that he was henceforth referred to as "Otto with the arrow", but the phenomenon casts a shadow on 13th century neurosurgery in Berlin, since apparently no one had dared to remove the arrow. We have no evidence of neurosurgical activity in Berlin in the late middle ages. This changed in the 18th century with the foundation of the Charite, a very progressive hospital for its time and a center for the training of military physicians. The spirit of medical practice at the Charite in the early years was influenced by the Dutchman BOERHAA VE, whose clinic at Leyden was known to the entire medical world. With all due regard to current knowledge in anatomy, physiology and chemistry, the guiding principle of BOERHAAVE's practice was his experience in practical medicine. Most physicians at the Charite were, directly or indirectly, pupils of BOERHAA VE, and his influence was extraordinary, as is evident in Frederick the Great's remark: "In medicine the professors must adhere to Boerhaave's method."
As described by DIEPGEN and HEISCHKEL, trepanation was one of the major operations that were current at the Charite:
"The primary indications are: removal of bone splinters, foreign bodies, hemorrhages and other effusions; depression of the skull and compression of the brain after injury to the head, the symptoms of which have been well described; more rarley, carious and purulent processes of the inner layer of the calvarium; and refractory headache. In hemiplegia, one seeks the lesion on the opposite side of the cranium, and if it is not found there, one may still apply the trepan to the other side. It seemed to be especially important to avoid cooling of the brain, for which reason the instruments were kept near a brazier, the room was kept warm and rinsing solutions and medications were heated before application. The drill-like crown trepan was used with great care, layer for layer. The dura mater was opened only if it was tense and showed fluctuation. Otherwise, it was treated with alcohol, in order to protect it from 'corruption'. If it was inflamed, bloodletting was performed. Prolapse of the brain was prevented by applying a lead or silver cap."
Trepanation was controversial even at the time, and rancor among colleagues was not uncommon, as is evident in the comment that Dr. PALLAS, of the Charite, "had placed the trepan on the suture and near the sinuses with the greatest audacity." In fact, PALLAS had warned against this and allowed trepanation at these two locations only in emergencies.
XI After the foundation of the University of Berlin in 1811 under the influence of Wilhelm von Humboldt and after establishment of the Royal Surgical Clinic in the Ziegelstra6e, surgery was well represented at the university, with two clinics, but the university itself stood entirely under the influence of the enlightenment, idealism and natural philosophy.
Fig. 1. Johann Friedrich Dieffenbach 1792-1847
In a speech at the 164th anniversary meeting of the "Gesellschaft fur Natur- und Heilkunde zu Berlin", Ewald HARNDT reported that the faculty of philosophy, guided by the spirits of FICHTE, SCHLEIERMACHER, HEGEL and SCHELLING, was dominant for decades and the "science" was understood exclusively as humane arts and sciences, not at all as natural science. So the "sciences of nature" were ranked as an adjunct to the philosophical faculty at the University of Berlin. In succeeding generations, the battle raged between proponents and opponents of trepanation. The second physician to occupy the chair for surgery in Berlin, Johann Friedrich DIEFFENBACH (Fig. 1), belonged to the latter group. DIEFFENBACH was an exceptionally versatile person, and he has been called the father of plastic surgery with some justification. Among his many publications is an article "On division of the sternocleidomastoid muscle in the treatment of wry neck", which appeared in 1838. In· 1828 he reported his experience with blood transfusion, and in 1845, in his book "Operative Chirurgie", he noted the influence of English surgeons on his work. In the same book, DIEFFENBACH reports that after unsuccessful division of the infraorbital nerve for treatment of trigeminal neuralgia, intracranial division of the V. nerve was considered but rejected as too risky. He recognized the advantages of ether anesthesia and published "An introduction to patient care" in order to improve nursing, which was apparently in a dismal state. The following lines are quoted from the "Introduction":
"What is the situation in the wards, for young men, especially for students? There is no cake and pastry there, as there is in the women's wards, but there is certainly beer and tobacco. Thick smoke fills the room. Men with mustaches and long pipes lie about on the sofas and chairs, and it is only with effort that one discovers the patient in bed as though on a palanquin. And among all these one finds a busy person
XII running back and forth, carrying beer, filling pipes and so on. That is the nurse! He often runs out of the room, as though to carry out an empty bottle, but he puts it to his mouth and takes a long draught. And then he smokes a few draughts of tobacco ... " DIEFFENBACH died while presenting a patient during a lecture. His successor, Bernhard von LANGENBECK (Fig. 2), took his chair for surgery in 1848. LANGENBECK, who had become lecturer in physiology and pathology in Gottingen in 1838, was decisively influenced by England in his development as a surgeon. He felt strongly attracted to Astley COOPER, who was the dean of British surgery, though almost 70 years of age, and who opened the doors of the Royal Medico-Chirurgical Society to LANGENBECK. His close ties to British surgery over several decades resulted in the nomination of PAGET, LISTER and SPENCER WELLS as the first honorary members of the Deutsche Gesellschaft fur Chirurgie, of which LANGENBECK was a co-founder.
Fig. 2. Bernhard von Langenbeck, 1810-1887
Gunshot wounds of the skull dominated LANGENBECK'S neurosurgical practice, since he was surgeon-general and entrusted with the education of Prussian military physicians (as was his successor, Ernst von BERGMANN). In addition, he was interested in the treatment of hydrocephalus. In this regard, there is the following reference on ventricular puncture in the "Handbuch der speziellen Pathologie und Therapie", edited by Rudolf VIR CHOW (1869): "Langenbecks method - which is to enter the anterior horn of the lateral ventricle from below, by introducing the trocar behind the upper eyelid and piercing the top of the orbital cavity - deserves special attention." He reported "On hypodermatic ergot injections in aneurysms" before the "Berliner Medizinische Gesellschaft" in 1869. In 1880 he presented a patient before the same society "On nerve repair with presentation of a case of secondary suture of the radial nerve". LANGENBECK was also able to report success in the surgical treatment of sarcomas of the skull and the dura mater with a
XIII procedure in which he removed part of the dura with the tumor. We today might suspect a number of meningeomas among these tumors. Ernst von BERGMANN (Fig. 3), LANGENBECK'S successor, came from Wurzburg to Berlin, as has DIEFFENBACH more than fifty years before and as would TONNIS more than 50 years later. Neurosurgery was his special interest, and his experimental work on intracranial pressure, begun in Dorpat and Wurzburg, established basic principles of the pathology of intracranial pressure which are still valid today. His observations on the symptoms of increased intracranial pressure, published in "Die Lehre von den Kopfverletzungen" in 1880, and his articles "Dber den Hirndruck" from 1885 and 1886 contain, together with the work of NAUNYN and SCHREIBER, most of the knowledge that had been rediscovered in this area in the past ten years.
Fig. 3. Ernst von Bergmann, 1836-1907
In the second edition of his "Chirurgische Behandlung der Hirnkrankheiten" (1888- 1889), von BERGMANN took an extremely critical position on attempts at surgical treat• ment of brain tumors, epilepsy and hemorrhage. The lists of papers, delivered before the "Gesellschaft fur Natur- und Heilkunde", the "Berliner Medizinische Gesellschaft" and the "Berliner Chirurgische Gesellschaft" contain about ten lectures per year on neurosurgical topics for the period of the 1890's and at the turn of the century (including addresses by BERGMANN'S pupils BORCHARD, GULEKE, KONIG, LEXER and SCHMIE• DEN), ample evidence of the enormous interest in the newly developed field of neurosurgery . In addition to the work at the university centers, surgeons in municipal and denominational hospitals performed neurosurgical operations. Eugen HAHN, a pupil of WILMS removed a brain tumor at the Bethanien Krankenhaus in 1882, making use of the diagnosis by WERNICKE. The Augusta-Krankenhaus, where Fedor KRAUSE (Fig. 4) was appointed head of a surgical department in 1900, was also a non-academic institution. KRAUSE had been trained as an ophthalmologist and then became director of the
XIV municipal hospital in Altona. His inaugural dissertation from the year 1887 dealt with malignant neuromas, and a monograph on trigeminal neuralgia appeared during his pe• riod in Altona. In 1892 HARTLEY and KRAUSE, independently of each other, described the extirpation of the Gasserian ganglion via the extradural approach from the floor of the middle fossa. As a result of the training in ophthalmology, KRAUSE was especially interested in the question of keratitis in relation to the ganglion extirpation. He did not limit himself to neurosurgery, as lectures on gastric surgery, reconstructive surgery of the ureter, of the mandible and free transplantation of large areas of skin, as well as major works in the fields of ophthalmology and bacteriology, a monograph on tuberculosis of the bones and joints and his textbook of surgical operations clearly show. He was enormously productive in the field of neurosurgery and described surgical approaches to almost all areas of the brain cavity. He was the first to employ the transfrontal intradural approach to the pituitary gland, and he performed the first exposure of the cerebellopontine angle and the first operative removal of a tumor in the lamina quadrigemina. In 1909 he reported his experience in 28 operations on the spinal cord, and in 1908 and 1911 he published his "Chirurgie des Gehirns und Riickenmarks", in which he not only described and illustrated surgical technique of the highest order, but also furnished exact statistics on a patient group that was exceptionally large for that period.
Fig. 4. Fedor Krause, 1857-1937
A surgeon such as KRAUSE, with interests in all fields of surgery, depended on the co-operation of an outstanding neurologist in order to succeed in neurosurgery. This neurologist was Hermann OPPENHEIM, who had published the first edition of his "Lehrbuch der Nervenkrankheiten" in 1894. OPPENHEIM, a pupil of WESTPHAL, had mastered neurology as no other at the time and pursued his medical and scientific activities with untiring effort despite a difficult professional and personal situation. The activity of Fedor KRAUSE and of his pupil and successor HEYMANN at the Augusta Krankenhaus made this house a center of neurosurgery, which was also cultivated by
xv SAUERBRUCH and others in the university hospitals in the 1920's and 1930's. The Surgical Congress of 1935 produced a break - in that neurosurgery was recognized as a separate speciality - and this lead to the appointment of TONNIS in Berlin 1936. TONNIS writes that he was able to begin work in the clinic at Hansaplatz on May 1, 1937 and that the British Society of Neurological Surgeons held its congress in Berlin and Breslau in June of the same year, in order to provide a fovorable start for TONNIS and his co-workers and to emphasize the significane of Berlin for european neurosurgery. The first efforts were, in fact, so successful that many foreign physicians came to Berlin for training in the short period before the outbreak of World War II. A large number of patients were treated also during the war in the first academic neurosurgical clinic in Germany, and many publications appeared, especially in the "Zentralblatt fur Neurochirurgie" which was founded by TONNIS.
Fig. 5. Arist Stender, 1903-1975
At the end of the Second World War, in which the neurosurgical clinics were destroyed, Arist STENDER (Fig. 5), who had been Otfried FOERSTER'S successor as director of the clinic in Breslau, began his work at the Augusta-Krankenhaus, where F. KRAUSE had worked. A few weeks later, he moved to the municipal hospital in Westend to develop a neurosurgical-neurological clinic where none had existed before. Shortly after the war, he successfully reestablished his earlier relations with the United States, and with his revered neurosurgical mentor Percival BAILEY. The basis of his practice, which encompassed the whole of neurosurgery, was neurological diagnosis. He was a master of this field and felt himself bound by a debt of gratitude to his teacher Max NONNE. Gangliolysis of the Gasserian ganglion carries his name. Trigeminal neuralgia was also a topic of major neurosurgical interest for Willy FELIX, SAUERBRUCH'S successor at the Charite. The
XVI quality of neurological and neurosurgical training in STENDER'S clinic is most evident in the fact that a large number of his pupils became successful physicians and scientists not only in the field of neurosurgery, but in neurology and neurophysiology as well. Berlin gained a second academic neurosurgical clinic with the construction of Klinikum Steglitz, where Wilhelm UMBACH became director until his untimely death. It was certainly not easy for Artist STENDER to accept a successor in his Westend clinic, who had been educated in an entirely different school and whose training was primarily in surgery rather than in neurology. Nevertheless, STENDER did so without prejudice and smoothed the way for him in Berlin. STENDER'S memory lives on in many hospitals in this city, as one can hear when his baltic cadence is parodied in jovial company, for anecdotes spring up only around personalities.
References
1. BEHREND, C. M.: Fedor Krause und die Neurochirurgie. Zentralb!. Neurochir. 2,122-127 (1938) 2. BERGMANN VON, E.: Die Lehre von den Kopfverletzungen. In: Deut. Chirurgie. Stuttgart: Enke 1880 3. BERGMANN VON, E.: Dber den Hirndruck. Arch. Klin. Chir. 32, 705-732 (1885) 4. BERGMANN VON, E.: Zur Erinnerung an Bernhard von Langenbeck. Berlin: Aug. Hirschwald 1888 5. BUCHHOLTZ, A.: Ernst von Bergmann. Mit Bergmanns Kriegsbriefen von 1866, 1870/71 und 1877. Leipzig: Vogel 1911 6. DIEPGEN, P., HEISCHKEL, E.: Die Medizin an der Berliner Charite bis zur Grundung der Universitat. Berlin: Springer 1935 7. Gesellschaft fur N atur- und Heilkunde in Berlin 1810-1960. Festschrift zur Feier ihres 150. Geburtstages am 6. Februar 1960. Berlin: Sagerdruck und Verlag 1960 8. HARNDT, E.: Das Wirken der Gesellschaft fur Natur- und Heilkunde im 19. Jahrhundert. Berlin: 1974 9. HASSE, K. E.: Krankheiten des Nervensystems. In: Handbuch der speziellen Pathologie und Therapie. 2nd ed., Vo!' IVI1. VIRCHOW, R. (ed.). Erlangen: Enke 1869. 10. KRAUSE, F.: Chirurgie des Gehirns und Ruckenmarks nach eigenen Erfahrungen. Vo!' 1.2. Berlin, Wien: Urban & Schwarzenberg 1911 11. LAMPE, R.: Dieffenbach. Leipzig, Barth 1934 12. NAUNYN, B., SCHREIBER, J.: Dber Gehirndruck. Arch. Exp. Patho!' Pharmako!. 14, 1(1881) 13. OPPENHEIM, H.: Lehrbuch der Nervenkrankheiten in 2 Banden. Berlin: Karger 1894 14. SCARFF, J. E.: Fifty years of neurosurgery 1905-1955. Surg. Gyneco. Obstet. 101,417-513 (1955) 15. TONNIS, W.: Die Entwicklung cler N eurochirurgie an cler Friedrich-Wilhelm-U niversitat zu Berlin von der Reichsgrundung bis 1945. In: Gedenkschrift der Westdeutschen Rektorenkonferenz und der Freien Universitat Berlin zur 150. Wiederkehr des Grundungsjahres der Friedrich-Wilhelms-Universitat zu Berlin, Studium Berolinense, Berlin: de Gruyter 1960
XVII Fedor Krause Memorial Lecture
Held on the occasion of the conferring of the Fedor Krause Medal on Professor Peter Rottgen by the German Society for Neurosurgery on May 5th, 1978, in Berlin.
Reflections of a Neurosurgeon: Splendor and Trials of a Dedicated Neurosurgeon
P. ROTTGEN
You have conferred the Fedor Krause medal on me, the highest distinction of our Society. That it is the Fedor Krause medal has pleased most the surgeon in me, and I wish to thank you very much indeed. When a man has discarded the vanity of the first decades of life, as things have assumed other dimensions, his pleasure need not thereby become less. But one asks one's self with more self-criticism, how one has deserved this honor. After all, one cannot simply compare the high standard of German neurosurgery today, to which one is proud of having contributed, with that of the man depicted on the medal. This man can only be seen in relation to his own time, in which he did pioneer work for the whole surgical world and in which he did so much so excellently for the first time. Sometimes his achievements were important enough to be covered by two names, as is the case for the Krause-Dandy-flap. I should like to recall the well-known phrase of Schiller, whose name, as well as Goethe's, is always mentioned on such occasions: "Whoever has satisfied the best people of his time" ... that is you, who confer medal ... "has lived for all times". This is too flattering as regards me, I must admit, and I do hope, all my friends agree with me in this respect. For my lecture I have chosen a general theme, as fits a man of my age. This does not mean, though, that there is nothing more to say about the present problems of neurosurgery, mainly if we consider that especially in the last few years, reliability of diagnosis and therapy has made extraordinary progress, which, in my opinion, can only be evaluated properly by those who have witnessed the beginnings. When a devoted neurosurgeon is about to leave the operation-theatre, which until then has represented the essential part of his professional life, and, tired and happy, is to retire to that proverbial bench under the beautiful tree, then he is asked by his friends and pupils, even with a certain right, to look into the mirror of his life. With age, such a mirror becomes agreeably dim. The contours are somewhat blurred and man's faculty to see things as they should be grows stronger. Well, I have always been known for naming disagreeable things by their name. Thus, I should not, I suppose, make exception to myself. After having tried to give the mirror a polish, I began to realize that also its owner had, himself, changed in his evaluation of things. "The clock calling me to duty" became more and more unbearable. Administrating and running even such a magnificent clinic
XVIII became rather burdensome. The classification of the gliomas became less important than that of, say, the conifers. More and more resignation crept into the battle for the life and the health of the patient. Even operating often turned out to be more of a burden than an exciting life elixir. I think it is not true to say that parting with beloved things makes the heart grow fonder; that is, I suppose, only true with regard to people, as e. g. our colleagues. First question of the mirror's owner to the mirrored picture: Do you really leave your place with pleasure? Answer: Yes, definitely! A few years ago he would still have answered with the ambiguity of the Rhenish peasant - with the greatest pleasure, if I must. To be able to free oneself is, I presume, in the whole nature, sign of increasing maturity. He who has not worked enough by the age of 68 is not likely to add anything essential through his later achievements. Second question to the picture in the mirror: Do you really believe that you are irreplaceable? Grin of relief and the firm and earnest answer: my dear friend, if the youngsters do not become better than wie older ones, we shall have failed pitifully. And I am glad to be able to attest that there are so many pupils who more and more surpass their master. After these silly questions the mirror's owner turned away from his likeness and thought on his life's dearest hobby: Neurosurgery. I have seen the time when the neurologist alone diagnosed the seat of a brain tumour,.or perhaps not, and when he showed the general surgeon the place where the tumour was,.or was not. The latter then tried to peel it out of the brain with his finger as he would have done with a prostatic adenoma. As I became more and more acquainted with contrast-medium diagnosis I was unorthodox enough towards my love of neurology so as to consider the following statement, attributed to the Prague neurologist Gamper, as an expression of the resignation of the neurologists: "Tumours are much too coarse formations to be detected by the refined neurological methods." Soon I learned to reject as a prejudice, the demand of neurologists for "more neurology and less Iodipin" in spi• nal diagnosis. A completely spiritless machine which allows a quick, reliable, safe and painless diagnosis, such as the computerized tomograph, transforms clinical pathology into an epitheton omans (i. e., a decorative extra) or, to put it bluntly, the reflex hammer is an archaic relic. A diagnostic method, however interesting it may be, must not be an end in itself. We all were enthusiastic about Kroll's "Syndromdoktrin" and believed in its validity. But I shall never forget the blow that this doctrine received when one of the authorities in clinical brain pathology refused to admit a tumor of the corpus callosum that was shown to him by Tonnis at surgery: "It cannot be there, it does not fit into the symptomatology" .
What a blessing to have grown up in a school in which the aim of therapy is the healing of the patient, irrespective of the method used. Our surgical technique must be as sparing, as quick, and as radical as possible. In this respect neurologists performing neurosurgical operation differ from neurological surgeons. Sparing means cautious and not hesitating or without decision. Nowadays the surgeon is made cautious by the microscope through which he sees much better what can be destroyed by him and what broad movements he makes. Today speed has no longer the importance it used to have in procedures performed under local anesthesia. But slowness is not synonimous of precaution. It is
XIX usually due to lack of decision and aim against which the surgeon must firmly fight. Radical surgery has its limits where the patient's life begins to be in danger and additionally in the case of brain surgery where a radical operation would destroy the essential, i. e. the mental life of the patient. Let me refer again to the subtitle of my lecture: Splendour and trials of a neurosurgeon. I would like to deal with splendour first. . Iatros gar aner pollon antaxios allon, Homer already said: "Doctor is a man that counts for more than many others". This is, of course, valid, above all for the best sort among the medical species: the neurosurgeon, who works at what is noblest in man, his brain. Let us be sincere: Whom of us does not delight himself in this bliss of having succesfully accomplished a major or minor operation, and of being able to say to himself : You have saved this patient's life or at least many years of it. Here I cannot help recalling a dictum of the great Billroth: "Only the simpletons are modest". That may sound hard to us today, but a surgeon who is not convinced of his worth cannot endure the daily toil. And why should he not be proud of it when he has done something particulary well or has done it for the first time, or, even, has done something new. Only, he should not think that his progress corresponds to the progress of all neurosurgeons in the world, and that all this has an eternal value. He even must wish that this progress may soon be surpassed. Thus, the most valuable results of his work are his pupils, of whom he therefore may be particulary proud, mainly when they belong to the elite of the neurosurgeons of this country.
Having said this, we may leave the "splendours" and turn to the larger and less agreeable chapter of "trials" of a surgeon's life. Defeats are always painful, even when expected, and when the best has been done. "Ultra posse nemo ooIigatur" - nobody can be challenged beyond his faculties - the Romans said, rightly and with insight into human nature. Only, all such maxims are equivocal. Before a neurosurgeon can appeal to this dictum he must ask himself whether he has done enough, and that always anew, to be at the height of his abilities, or whether he has undertaken too little both intellectually and technically prior to starting a procedure. He must also ask himself whether he kept enough self-command during it, whether he had sufficient control of his emotions, whether he made false decisions, whether he was sufficiently prepared, also physically, for instance due to those prolonged festivities the night before, etc. I do not want to enlarge on this. Whoever has operated on more than one brain tumour has probed his conscience at least occasionally, and is not completely possessed by the greatest vice of all, spiritual pride. He will not be able to acquit himself altogether and he will be well advised to keep this in mind when remembering the dead. The sentence about this will have to be pronounced to oneself privately. I am sure that such a probing of one's professional conscience is practised by the surgeons, those among all doctors who certainly need it most, more often than the layman would expect. In my youth it was an admired feature of the great surgeon that he gave way to his emotions at the operation table. The young assistant accepted this, as all weaknesses, with special pleasure. Today silence reigns in the modern operating theatres, among the real masters of the scapel. The reasons are various: The great demand for sterility, the concentrated work, especially in the teams where members have equal rights and cannot be treated as the little surgical nurse or the young assistant used to be. The reasons for controlled behaviour lie in simple humane education. But, who still believes in xx the pedagogic value of self-discipline? Who realizes, for example, that showing one's feelings stirs the emotions whereas self-discipline suppresses their rise? To exemplify this should also be part of the training in the operating room, even if the temperamental master does not always succeed in it, just as he also surely does not work without making mistakes. That one makes mistakes should not lead the greatest "demi-god in white" into disgrace. That has always been so and will remain so. That we are confronted with a wave of legal proceedings for liabilities has many reasons. We should certainly not gloss over real mistakes that occur, also in neurosurgery. It is, however, more and more obvious that the strongest reason for such law-suits is the artificially fostered envy in our present-day society, here as well as everywhere. One has given it a polite name ("Sozialkritik") as a palliative for the naive and stupid. I have no desire, however, to dwell further on that. Every surgeon is given a comparatively wide scope for his indications .. One has tried again and again to pose general rules. In spite of this, the individual limitation remain large. It also depends on the personality of the surgeon, his character, his temperament, his training, his sense of responsibility and, as some believe, also on his smartness, which, in my view, is a bad counsellor. It is easy to be smart if one endangers other people. Indications that are influenced by non-medical motives, e. g., money, can certainly be a great temptation, especially today, in a world that is growing more and more materialistic. The neurosurgeons, with theire extensive and dangerous operations are, I suppose, less endangered in this respect. But does this ethos not waver easily when medical renown is at stake? Must we not now and then recall to our minds that medical curiosity alone is not sufficient for an indication? Neither true research nor the longing for scientific fame can be a justification for degrading man to a guinea-pig. My friends, we must not belittle this problem; with every implanted probe we must keep in mind not only the principle of "nil nocere" but also the question to whom it is of use. The decision to operate is particularly difficult with tumours of the brain that have already been diagnosed as malignant. One often hears the opinion that one should not operate on such cases. I think one cannot always maintain this view. One is bound to take into consideration the patient's chance of a change for the better in the short or the long run. Nor can one in general exclude all metastases from an operation. Of course it does not make sense to operate on the brain in the case of an inoperable primary cancer and numerous metastases. But a suspected monocular metastasis, which is not at all rare, can indeed be worth operating on following the extirpation of the primary tumor. I shall never forget a young lady doctor who reported to me that a choreo-epithelioma had been apparently radically extirpated some weeks prior, and that she now had a metastasis in the left occipital lobe. She had brought with her the arteriogram and a neurosurgical report I!aying the tumor was inoperable. I was really of the same opinion, but I did not have the heart to confirm to the colleague sitting in front of me, that she was doomed. I told her, I did not agree, and that one should, for God's sake, have a try. As it happened, it was the only metastasis I was able to extirpate in toto in 1950. A few days ago, after 28 years, I re• ceived the latest confirmation of this in a letter, reporting that she was still well-off. Such a case compensates for many others in which one has tried in vain. This also applies to metastases of the spinal cord operated on at an early stage, in which a patient who is
XXI doomed to being bedridden and badly paralysed for many months by a transverse lesion of the cord can be saved. Thus, one should not say that one should never try. In neurosurgery also it is, in the last instance, the personal fate of the individual that counts. This also applies in particular to the heavy cross all neurosurgeons have to bear, the glioblastoma, and to similar tumors. Apart from the case of centrally seated tumours, the decision to operate can only depend on the question of whether eventually there will remain a patient who can still be considered a human being, or one that merely vegetates. A patient can live with a paralysis, but not with a grave psychic brain damage, with aphasia, agnosia, and pronounced changes in his intrinisic nature. To live six or eight months, or a year longer may be both subjectively desirable and objectively valuable. May not subspecies aeternitatis, a man who is facing death, attain his spiritual fulfilment only then? Of course, the spiritual strength of the patient as well as that of his helpers and friends are of need for this. What we should beware of, however, in such cases, is to try and attain medical perfection which, in the last instance, does not achieve anything, at least at present. That means we should beware of instant X-ray treatment, cytostatic drugs, etc., with which we can spoil the patient's happy month after surgery. We therefore irradiate only recurrencies. But to prolong a small child's life by a few months usually only amounts to prolonging its suffering. Our efforts to operate on all tumors as radically a possible, end where the human being as such reaches its limits, not to mention the fact that every effort of forced radicality precludes success. The neurosurgeon had better rest content with less in this case.
It is a blessing that the neurosurgeons also have to deal with less difficult cases, especially for the young colleagues who, thus, can be trained more easily. The young surgeon, of course, has the same feeling that we all had when we began: one is not allowed to do anything oneself early enough. Only the trouble is that once he has the scalpel in his hand by himself, nobody can help him, at least not in the critical situation. It is a heavy burden for the senior surgeon responsible having to tell himself: if only you had done it yourself. One does not fully realize this until one has the ultimate responsibility of a senior surgeon oneself. Youthful recklessness is a feature of the grand old surgeon only in the movies, where he then makes a good figure. His surgeon's soul grows, however, more vulnerable the older he becomes. Contrary to popular opinion, losses and defeats on the operation table hurt more the older one gets. However, to be quite frank - as promised - I am not sure wheter and to what extent it is hurt pride, "that such a thing could have happened to him", the old experienced silly ass.
May I add a word on the often inhuman way people have to die in clinics. Gottfried Benn, who was a doctor, once said: "Life in a hospital is bitter and one dies there without a vine-wreath in one's hair". What the poet wants to express by this metaphor is what relatives and friends often observe and consider undignifying. This applies in particular to our modern intensive care unit. Neurosurgery can be proud of having been the first operative discipline to install intensive care wards long before there were anesthetists. Certainly visitors must be kept out of the intensive care units for good reasons, such as to inadequate asepsis, a restful atmosphere, and undisturbed work. But this isolation only makes sense as long as there is hope for the patient to be cured. When it becomes obvious that all medical activity has become in vain, either the patient should be transferred or the
XXII room should be opened to visitors, so that the dying man does not spend his last hours alone without family and friends. Medical equipment of the most modern perfection should, of course, be part of the outfit of an intensive care unit. But the extent to what it must be used in a particular case, i. e. a perspective of success, is a serious decision, which the surgeon must make. Scientific medicine is only one aspect of our therapy, and it does not take into account the entire patient. When death approaches, the human aspect of medicine must take the lead. There is no doubt that here much is left to be desired in our clinics. Thank God that death is merciful with most neurosurgical patients. Often kind nature protects them with the cloak of unconsciousness. But these patients must not simply perish in a lonely room either. The next of kin have, in my view, not only the right but also the duty to be present, and it is only to the good of the visitor to stand by someone who is dying. In this context allowed me to say also a few words about euthanasia. Euthanasia is no serious medical problem. It is the doctor's duty to help. He is allowed to stop treatment when he cannot help any longer, he even ought to do so. This is not, as people sometimes say mistakenly, passive euthanasia. Man has the right to a natural death. A doctor cannot be called upon to kill old people whose lives have become useless, or to eradicate people unfit for life. What is usually asked for, by the way, is not that the patient have a merciful death, but that the relatives may get rid of the dying patient. In my long career it happened once that a patient, who was suffering from a recurrent tumour, genuinely asked me to relieve him from his sufferings. On the other hand, many relatives have approached me to say that the sufferings of the patient were so great that one ought to put an end to them. LadiE~ and gentleman, I would very much have liked to say something about what attracted me to neurology and later to neurosurgery fourty-five years ago. It was the relationship between the brain and the soul. This might have been quite an appropriate subject here in Berlin, where the Frenchman Lamettrie, who was in the service of Frederic the Great, died in 1751. He declared, as you know, that the brain produces the thoughts as the gland the saps. The modern equation "brain = computer" does not appear to me much better either. Contemporary quantum physicist have proven, for the first time, through the radioactive decay, that a true indetermination and no causality prevails in this process. Max PLANCK said: "An event is causal, if it can be predicted with certainty. The lack of the principle of causality must also be postulated for the other end of the cosmos, i. e. the mind. Our thoughts can be predicted as little as the courses of the ions." Thus, to me, the best, perhaps too metaphysical, notion of the relationship between the brain and the mind is that of my neurology teacher and friend LAUBENTHAL, who follows BUMKE'S notion that we are still moving in the forecourt of the soul with our psychopathological ideas about the function of the brain. According to him, the human mind plays on the brain like the organ-player on his instrument. Each year we become more acquainted with the instrument, i. e. the pipes, and of course, also with the air producing the sounds there in. Of the player, however, we do not know more than Plato or other thinkers, not to mention the composer of sonorous music who has surely composed many more cantatas, sonatas, and even entire symphonies, which have never yet come out of the organ-pipes. As I said, this is only a metaphor. The neurosurgeon, who is for the greater part an artisan, lacks the philosophical training which, perhaps, he ought to have. But, to come to an end: what in the world should the ideal neurosurgeon be: an impeccable diagnostician, an infallible operator, a good-natured teacher who never explodes and always thinks of the well-being of his pupil, an excellent scientist, and what
XXIII all, in order to be a good doctor? Although you have conferred the medal to me, all who know me will now think that also as far as I am concerned there are some spots here and there in this ideal picture. My answer: the ideal picture always hangs so high that one does not reach it. It should be looked at as an indication of one's aim as long as one is young; it should be talked about as I have done just now when one has grown old and realizes that one has not succeeded in attaining it. I thank you for having listened to me so patiently.
XXIV Contents
Treatment of Hydrocephalus
Wo LEEM and Ho MILTZ: Complications Following Ventriculo-Atrial Shunts in
Hydrocephalus 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 Eo Wo STRAHL, J. LIESEGANG, and K. ROOSEN: Complications Following
Ventriculo-Peritoneal Shunts 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 6 Eo GROTE, J. ZIERSKI. Mo KLINGER, Go GROHMANN, and Eo MARKAKIS:
Complications Following Ventriculo-Cisternal Shunts 0 0 0 0 0 0 0 0 0 0 0 0 10
Ro V 0 JEFFREYS and Mo CHIR: The Complications of Ventriculo-Atrial Shunting in
Hydrocephalus 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 17 J. C. DE VILLIERS, Po Fo DE Vo CLUVER, and L. HANDLER: Complications
Following Shunt Operations for Post-meningitic Hydrocephalus 0 0 0 0 0 0 0 23
Go THo V. BEUSEKOM: Complications in Hydrocephalus Shunting Procedures 0 0 0 28 C. No TROMP and Wo VAN DEN BURG: Surgically Treated Infantile Hydrocephalus
and Predictability of Later Intelligence 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 31
Go BLAAUW: Hydrocephalus and Epilepsy 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 37 So SALAH, Mo SUNDER-PLASSMANN, F. ZAUNBAUER, and Wo Koos: The Use of the Anti-Siphon-Value in the Prevention of Functional Complications of
Shunting System 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 42 Zo Do GOEDHART, Ro Eo Mo HEKSTER, and Bo MATRICALI: Neurosurgical and
Neurological Applications of the Ommaya Reservoir System 0 0 0 0 0 0 0 0 0 45 Ao Do HOCKLEY and Ao Eo HOLMES: Computerized Axial Tomography and Shunt
Dependency 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 48 Ho FRIEDRICH and Go HAENSEL-FRIEDRICH: Perioperative Chemoprophylaxis in
Shunting-Infections 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 52
Computer Tomography
J. SMALL: Impressionist Mechanical Mind of Man 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 59 Vo L. McALLISTER, J. HANKINSON, and Ro Po SENGUPTA: Problems in Diagnosis
With Computerized Tomography (CT) 0 0 0 0 0 0 0 0 0 0 0 0 0 • 0 0 0 0 0 0 61 TH. GRUMME, Ko KRETZSCHMAR, Go EBHARDT, Wo LANKSCH, and So LANGE: Intracerebral Space-Occupying Lesions With Brain Density (Isodense
Lesions) 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 75 Eo KAZNER, Ho STEINHOFF, So WENDE, and Wo MAUERSBERGER: Ring-Shaped
Lesions in the CT Scan - Differential Diagnostic Considerations 0 0 0 0 0 0 0 80 CHo Bo OSTERTAG and Fo MUNDINGER: Diagnostic Errors in the Interpretation of
Cerebral Infarction 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 86
XXV J. R. BARTLEIT and G. NEIL-DWYER: A Clinical Study of the EMI Scanner With Implications for the Future Distribution of Neuroradiological Services . . .. 94 C. E. POLKEY: The Correlation Between EMI Scan Appearances and the Pathologic Findings in a Small Group of Patients Submitted to Anterior Temporal Lobectomy forIntractable Epilepsy ...... 98 W. 1. STEUDEL, .T. KRUGER, TH. GOLLER, and H. GRAU: Computer-Tomogra- phy as Applied to Early Posttraumatic Epilepsy ...... 106 R. MUKE and D. KUHNE: Diagnostic Errors in Computerized Tomography in the Differential Diagnosis of Cerebrovascular Lesions ...... " 115 H. E. CLAR, W. J. BOCK, and H. C. WIECHERT: Correlation of Hyperdense and Hypodense Areas in the Computerized Tomogram of Subdural Hematomas. 125 1. SCHOTER and J. WAPPENSCHMIDT: Difficulties in the Interpretation of Computerized Tomography ...... " 131
Free Topics
M. R. FEARNSIDE and C. B. T. ADAMS: Clinical Deterioration and Intracranial Pressure Patterns Following Aneurysm Surgery ...... 139 R. A. C. ] ONES: Aneurysms in the Elderly ...... 144 B. PERTUISET and J. P. SICHEZ: The Backward Technique in the Total Excision of Cerebral Arteriovenous Malformations: Experience With 86 Cases ...... 148 T. A. LIE: Fibromuscular Dysplasia ...... 154 W. PONDAAG: Disseminated Intravascular Coagulation in Head-Injured Patients. 159 W. J. OVERBECK: Operative Angiography...... 164 W. LUYENDYK and R. THOMEER: Basilar Impression in Chondrodystrophy. . .. 176 P. GORTVAI, J. DE LouvOIs, and R. HURLEY: Incidence and Mortality of Abscesses of the Central Nervous System in England and Wales - Results of a Survey...... 178 R. E. H. VAN ACKER: Immunologic Aspects of Malignant Gliomas...... 182 A. BAETHMANN, W. OrrINGER, B. FLEISCHER, K. MORITAKE, and F. ]ESCH: Corticosteroids Stimulate Cerebral Energy Metabolism; Support for a Metabolic Action of Steroids on Brain Edema ...... 187 M. GAAB, K. W. PFLUGHAUPT, M. RATZKA, R. WODARZ, and P. GRUSS: Critical Intracranial Effects of Osmotherapy ...... 193 H. E. CLAR, L. GERHARD, and V. REINHARDT: Experimental and Morphologic Investigations on Reversible and Irreversible Hypothalamic Compression in the Rabbit ...... 206 G. MEINIG, H. J. REULEN, K. DEI-ANANG, and K. SCHURMANN: Treatment of Peritumoral Brain Edema ...... 212 H. SCHLARB and M. SCHIRMER: Pinealoma With Initial Spinal Manifestation 221
Subject Index ...... 225
XXVI List of Senior Authors
VAN ACKER, R. E. H.: Department of Neurosurgery, University Hospital Wilhelmina Gasthuis, Amsterdam (Niederlande)
BAETHMANN, A.: Institut fiir klinische Forschung an der Chirurgischen Klinik der Ludwig-Maximilians-Universitat Miinchen, Nussbaumstrasse 20, D-8000 Miinchen 2 (FRG) BARTLETT, J. R.: Consultant Neurosurgeon, Brook General Hospital, Shooter Hill Road, London, SE18 4LW (Great Britain) VAN BEUSEKOM, G. TH.: Feldveg 22, Hattum (Niederlande) BLAAUW, G.: Department of Neurosurgery, Academic Hospital Rotterdam-Dijkzigt, Rotterdam (Niederlande)
CLAR, H.-E.: N eurochirurgische Universitatsklinik, Hufelandstrasse 55, D-4300 Essen 1 (FRG)
FEARNSIDE, M. R.: The Department of Neurological Surgery, The Radcliffe Infirmary, Oxford, 0X2 6HE (Great Britain) FRIEDRICH, H.: Neurochirurgische Klinik, Abteilung Allgemeine Neurochirurgie, Universitat Freiburg, D-7800 Freiburg i. Br. (FRG)
GAAB, M.: Neurochirurgische Klinik der Universitat Wiirzhurg, Kopf-Klinik, Josef• Schneider-Strasse 11, D-8700 Wiirzburg (FRG) GOEDHART, Z. D.: Slotervaart Ziekenhuis, Louwesweg 6, Amsterdam (Niederlande) GORTVAI, P.: Regional Centre for Neurology and Neurosurgery, Oldchurch Hospital, Romford, Essex (Great Britain) GROTE, E.: Neurochirurgische Universitatsklinik, Klinikstrasse 29, D-6300 GieBen (FRG) GRUMME, TH.: Neurochirurgische Klinik der Freien Universitat Berlin im Klinikum Charlottenburg, Spandauer Damm 130, D-1000 Berlin 19 (FRG) GUTIERREZ, c.: Institut fiir Geschichte der Medizin und Neurochirurgische Klinik, Universitat Gottingen, D-3400 Gottingen (FRG)
HOCKLEY, A. D.: Department of Neurological Surgery and Neurology, Addenbroke's Hospital, Cambridge (Great Britain)
XXVII JEFFREYS, R. V.: Mersey Regional Department of Surgical Neurology, Walton Hospital, Rice Lane, Liverpool, L9 1AE (Great Britain) JONES, R. A. c.: Department of Neurosurgery, Salford Royal Hospital, Salford (Great Britain)
KAZNER, E.: N eurochirurgische Klinik im Klinikum Grosshadern der Ludwig-Maximi• lians-Universitat Miinchen, Marchioninistrasse 15, D-SOOO Miinchen 70 (FRG)
LEEM, W.: Neurochirurgische Klinik, Universitat Diisseldorf, Moorenstrasse 5, D-4000 Diisseldorf (FRG) LIE, T. A.: Neurosurgical Department, St. Elisabeth Hospital, Tilburg (Niederlande) LUYENDIJK, W.: Prinse Bernhardlaan 60, Oedstgeest (Niederlande)
McALLISTER, V. L.: Newcastle General Hospital, Westgate Road, Newcastle-upon• Tyne (Great Britain) MEINIG, G.: Neurochirurgische Universitatsklinik, Langenbeckstrasse 1, D-6500 Mainz (FRG) MOKE, R.: Neurochirurgische Abteilung, Neurologische Universitatsklinik Hamburg• Eppendorf, Martinistrasse 52, D-2000 Hamburg 20 (FRG)
OSTERTAG, CH. B.: Neurochirurgische Universitatsklinik Freiburg, Abteilung Stereo• taxie und Neuronuklearmedizin, Hugstetter Strasse 55, D-7S00 Freiburg i. Br. (FRG) OVERBECK, W. J.: Department of Neurosurgery, University Hospital, 59 Oostersingel, Groningen (Niederlande)
PERTUISET, B.: Service de Neurochirurgie, C.H.U. Pitie-Salpetriere, S3, Boulevard de l'Hopital, F-7513 Paris (France) POLKEY, C. E.: The Neurosurgical Unit, Maudsley Hospital, De Crespigny Park, London, SES AZ (Great Britain) PONDAAG, W.: Neurosurgical Centre Zwolle, Sophia Ziekenhuis, SOOO GK Zwolle (Niederlande)
ROTTGEN, P.: Neurochirurgische Universitatsklinik, Annaberger Weg, D-5300 Bonn• Venus berg (FRG)
SALAH, S.: Neurochirurgische Universitatsklinik Wien, Alserstrasse 4, A-1097 Wien (Austria) SCHLARB, H.: Stadtisches Krankenhaus Neukolln, Neurochirurgische Abteilung, Rudower Strasse 56, D-1000 Berlin 47 (FRG) SCHOTER, I.: Neurochirurgische Universitatsklinik, Annaberger Weg, D-5300 Bonn• Venusberg (FRG)
XXVIII SMALL, J. M.: Midlands Centre of Neurosurgery, Holly Lane, Smethwick, Warrick, BG7 JX (Great Britain) STEUDEL, W.I.: Neurochirurgische Universitatsklinik,Johann-Wolfgang-Goethe-Uni• versitat, Schleusenweg 2, D-6000 Frankfurt/Main (FRG) STRAHL, E.-W.: Neurochirurgische Klinik, Universitat Essen-GHS, Hufelandstrasse 55, D-4300 Essen (FRG)
TROMP, C. N.: Clinic of Neurosurgery, University State Hospital, Oostersingel 59, Groningen (Niederlande)
DE VILLIERS, J. c.: Department of Neurosurgery, Groote Schuur Hospital, Kaapstad (South African Republic)
WULLENWEBER, R.: Neurochirurgische Klinik, Klinikum Westend, Freie Universitat Berlin, Spandauer Damm 130, D-1000 Berlin 19 (FRG)
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